1. A charge nurse is dis- d. have family members wear a gown and gloves
cussing the responsi- when visiting
bility of nurses car-
ing for clients who A client who has a Clostridium difficile infection re-
have Clostridium diffi- quires a private room, but a negative airflow system
cile infection. Which of is not necessary.
the following informa- Use alcohol-based hand sanitizer when leaving the
tion should the nurse client's room. The nurse should use soap and wa-
include in the teach- ter for hand hygiene because alcohol-based hand
ing? sanitizer does not kill Clostridium difficile spores.
a. assign the client to Clean contaminated surfaces in the client's room
a room with a negative with a phenol solution.The nurse should use a phe-
airflow system nol solution to clean surfaces contaminated with
b. use alcohol-based bacteria and fungi. However, phenol does not kill
hand sanitizer when Clostridium difficile spores. Chlorine bleach is an
leaving the client's example of a disinfectant that kills spores.
room Have family members wear a gown and gloves
c. clean contaminated when visiting.Nurses are responsible for ensur-
surfaces in the client's ing that family members wear a gown and gloves
room with a phenol so- to prevent the transmission of Clostridium difficile
lution spores. Staff must also wear gowns and gloves.
d. have family mem-
bers wear a gown and
gloves when visiting
2. A nurse is giving b. breath sounds
change of shift report
about a client they ad- When using the airway, breathing, circulation ap-
mitted earlier that day proach to client care, the nurse should determine
who has pneumonia. that the priority information to provide is the current
Which of the following status of the client's breath sounds. Knowing the
pieces of info is the pri- client's admitting diagnosis is essential for planning
ority for the nurse to care and following critical pathways; however, other
provide? information is the nurse's priority to provide. Body
a. admitting diagnosis temperature
b. breath sounds Knowing the client's current body temperature is
c. body temperature essential for planning care and following critical
d. diagnostic test re- pathways; however, other information is the nurse's
sults priority to provide. Knowing diagnostic test results
, ATI Fundamentals Retake
is essential for planning care and following critical
pathways; however, other information is the nurse's
priority to provide.
3. A nurse is prepar- a. ambulating a client who is postop
ing to delegate client
care tasks to an as- Ambulating a client is within the range of function
sistive personnel(AP). of an AP. The nurse can delegate tasks to the AP
Which of the following that do not require special skills, assessment, or
tasks should the nurse teaching.
delegate? Inserting an indwelling urinary catheter for a cli-
a. ambulating a client entIndwelling urinary catheter insertion requires
who is postop advanced nursing judgment and sterile technique.
b. inserting an This task is outside the range of function of an AP.
indwelling urinary Demonstrating the use of an incentive spirometer to
catheter for a client a clientClient education requires advanced nursing
c. demonstrating the knowledge and is outside the range of function of
use of an incentive an AP.
spirometer to a client Confirming that a client's pain has decreased af-
d. confirming that a ter receiving an analgesicEvaluating a client's pain
client's pain has de- level requires advanced nursing judgment and is
creased after receiving outside the range of function of an AP.
an analgesic
4. A nurse enters a c. "client found lying on the floor"
client's room and finds
her on the floor. The An incident report is an internal document that is
client's roommate re- part of a facility's risk management system. The
ports that the client nurse should not document completion of an in-
was trying to get out cident report in the client's medical record for the
of bed and fell over the facility's protection in the event of litigation.
side rail onto the floor. "Client climbed over the side rails."Unless the nurse
Which of the following witnessed the client climbing over the bed's side
statements should the rails, this statement is not an objective account of
nurse document about the nurse's findings.
this incident? "Client found lying on floor." The nurse should in-
a. "incident report clude documentation of information that is descrip-
completed" tive and objective concerning what the nurse ac-
b. "client climbed over tually observed, without including any opinions or
, ATI Fundamentals Retake
the side rails" judgments about motives or cause.
c. "client found lying "Client was trying to get out of bed."Unless the
on the floor" nurse witnessed the client trying to get out of bed,
d. "client was trying to this statement is not an objective account of the
get out of bed" nurse's findings.
5. A nurse is caring c. cleanse the wound from the center outward
for a client who
has a prescription The nurse should wear clean gloves to remove the
for wound irrigation. old dressing.
Which of the follow- Warm the irrigation solution to 40.5° C (105° F).The
ing actions should the nurse should warm the irrigation solution to body
nurse take? temperature.
a. wear sterile gloves Cleanse the wound from the center outward. The
when removing the old nurse should clean the wound from the center out-
dressing ward to prevent introduction of micro-organisms
b. warm the irrigation from the outer skin surface.
solution to 40.5(105 Use a 20-mL syringe to irrigate the wound.The
degrees farenheit) nurse should use a 35-mL syringe to irrigate the
c. cleanse the wound wound. Syringes that hold 30 to 60 mL of fluid
from the center out- create a safe but effective amount of pressure for
ward wound irrigation.
d. use a 20 mL syringe
to irrigate the wound.
6. A nurse is admitting a a. droplet
client who has rubel-
la. Which of the fol- Droplet precautions are a requirement for clients
lowing types of trans- who have infections that spread via droplet nuclei
mission based precau- that are larger than 5 microns in diameter, including
tions should the nurse influenza, rubella, meningococcal pneumonia, and
initiate? streptococcal pharyngitis.
a. droplet Airborne precautions are a requirement for clients
b. airborne who have infections that spread via droplet nuclei
c. contact that are smaller than 5 microns in diameter, includ-
d. protective environ- ing varicella, tuberculosis, and measles.
ment Contact precautions are a requirement for clients
who have infections that spread via direct con-
tact with another person or contact with the en-
, ATI Fundamentals Retake
vironment, including vancomycin-resistant entero-
cocci, methicillin-resistant Staphylococcus aureus,
and scabies.
Protective environment Clients who have a com-
promised immune system, such as those who have
had an allogeneic hematopoietic stem cell trans-
plant, require a protective environment.
7. The nurse is provid- a,c,d
ing discharge teaching
for a client who has Check the cord routinely for frays or tearing is cor-
a new prescription for rect. Oxygen concentrators require electrical pow-
a home oxygen con- er. Safe use of this delivery system includes as-
centrator. Which of the sessing the electrical function of the device; there-
following instructions fore, the nurse should instruct the client to routinely
should the nurse pro- check the condition of the cord.Keep the unit at
vide to the client and least 1.2 m (4 feet) away from a gas stove is incor-
his family? select all rect. Safe use of home oxygen equipment includes
that apply. keeping the unit at least 3.05 m (10 feet) away from
a. check the cord rou- open flames, such as from a fireplace or a gas
tinely for frays and stove, and at least 2.4 m (8 feet) away from other
tearing heat sources.Consider purchasing a generator for
b. keep the unit at least power backup is correct. Loss of electricity prevents
1.2 m (4 feet) away the oxygen concentrator from functioning and could
from a gas stove deprive the client of necessary oxygen. The nurse
c. consider purchasing should also instruct the family to have the client
a generator for power placed on their municipality's priority list for restor-
backup ing power after an outage occurs.Observe for signs
d. observe for signs of of hypoxia is correct. The nurse should instruct the
hypoxia family to observe for
d. select synthetic
clothing and bedding
8. A nurse is calculat- c. 8 oz of ice chips
ing a client's fluid in-
take over the past 8 2 cups of soup. The nurse should understand that
hr. Which of the follow- 2 cups of soup are equivalent to 480 mL of fluid.
ing should the nurse 1 quart of water. The nurse should understand that
plan to document on 1 quart of water is equivalent to 960 to 1,000 mL of
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